new patient Form

The information requested below will assist in the practitioner treating you safely. Feel free to ask any questions about the information being requested. Please note that all information provided below will be kept confidentially unless allowed or required by law; your written permission will be requested to release any information.

Date:

Date:

MM

DD

YYYY

Personal History

1. Title:

Dr.

Mr.

Mrs.

Ms.

2. Name: *

2. Name:

First Name

Last Name

3. Date of birth:

3. Date of birth:

MM

DD

YYYY

4. Address:

4. Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

5. Home phone:

5. Home phone:

(###)

###

####

6. Cell phone:

6. Cell phone:

(###)

###

####

7. Email address:

8. Occupation:

9. Reason for today's visit:

10. Western medical diagnosis:

11. Family physician:

12. How did you hear about this clinic?

Social Media (Facebook, twitter, etc.)

Internet search

Friend or Family (please list their name below)

Yellopages

Other (please list below)

13. Emergency contact:

13. Emergency contact:

First Name

Last Name

14. Emergency contact's phone number:

14. Emergency contact's phone number:

(###)

###

####

15. Alberta Health Care Number:

16. Do you have insurance? *

If you answer yes, please tell us the name of insurance company

Yes

No

Name of insurance company:

Required Field *

I understand that in the event my insurance carrier does not pay for treatment provided to me, I will be responsible for payment.

17. East Meets West Health Centre would like your permission to contact you by email for appointment reminders, promotional offers, etc.